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Neurogenic bowel, sexuality and fertility in spinal cord injury

What decides the bowel programme and sexual function is whether the sacral reflex arc (S2–S4) is intact: with an injury above the conus the bowel is "reflexic" and reflex erection is possible; with a conus or cauda equina injury the bowel is "flaccid" and the reflexes are lost.

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Why it matters in the exam

Reflexic neurogenic bowel (upper motor neuron injury, above the conus): the external sphincter is spastic and transit is slow, so the main problem is constipation and stool retention. The programme: regular evacuation (daily or every other day) after a meal to use the gastrocolic reflex, digital stimulation, suppositories (for example bisacodyl), and soft, formed stool. Flaccid bowel (lower motor neuron, conus or cauda equina): the sphincter is lax and there is no reflex, so there is both constipation and leakage; the programme: daily manual evacuation, sometimes more than once a day, and firmer stool to limit leakage. When the programme fails — transanal irrigation, and in selected cases a stoma, which improves quality of life.

Sexual function in men: reflex erection depends on segments S2–S4, and psychogenic erection on the sympathetic pathway T11–L2. In a high complete injury reflex erection is preserved but not sustained; in a conus injury it is lost. PDE5 inhibitors are the first treatment (care with orthostatic hypotension), followed by intracavernosal injections and a vacuum device. Ejaculation is impaired in most men; penile vibratory stimulation (requires an intact reflex arc) or electroejaculation is used to obtain semen. Semen quality is poor — mainly low motility — and fertility techniques are sometimes needed. With an injury at T6 and above, vibratory stimulation can trigger dysreflexia, so blood pressure is monitored and nifedipine is sometimes given beforehand.

Women: menstruation often stops for a few months after injury and then returns, and fertility is usually preserved. In pregnancy there are more urinary infections, thrombosis, pressure injuries and constipation; contractions may not be felt with a high injury, so close follow-up towards delivery must be planned. With an injury at T6 and above, labour can trigger dysreflexia, and epidural anaesthesia is recommended to prevent it. Sexual counselling is part of rehabilitation, and the question about sexuality should be asked proactively.

Key points

• UMN bowel — reflexic and retaining; LMN — flaccid and leaking.
• UMN: after a meal, digital stimulation and suppositories.
• LMN: daily manual evacuation.
• Reflex erection — S2–S4; psychogenic — T11–L2.
• Woman with a high injury — epidural in labour.

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Sources

• PVA Consortium for Spinal Cord Medicine: Management of Neurogenic Bowel Dysfunction in Adults after Spinal Cord Injury, 2020 — Bowel programme for reflexic and areflexic bowel
• PVA Consortium for Spinal Cord Medicine: Sexuality and Reproductive Health in Adults with Spinal Cord Injury, 2010 — Erection, ejaculation, fertility and pregnancy

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.